Introspection

Words I should try to live by:

So live your life that the fear of death can never enter your heart.
Trouble no one about their religion;
respect others in their view, and demand that they respect yours.
Love your life, perfect your life, beautify all things in your life.

Seek to make your life long and its purpose in the service of your people.
Prepare a noble death song for the day when you go over the great divide.
Always give a word or a sign of salute when meeting or passing a friend,
even a stranger, when in a lonely place.
Show respect to all people and grovel to none.

When you arise in the morning give thanks for the food and for the joy of living.
If you see no reason for giving thanks, the fault lies only in yourself.

Abuse no one and no thing, for abuse turns the wise ones to fools
and robs the spirit of its vision.

When it comes your time to die, be not like those whose hearts are filled
with the fear of death, so that when their time comes they weep
and pray for a little more time to live their lives over again in a different way.
Sing your death song and die like a hero going home.

(Often attributed to Tecumseh)

I understand this as a more eloquent reminder to live your life with no regrets, and grasp each day to its fullest. A simple idea in the grand scheme of things, yet more of a challenge in the day-to-day grind. 

Big news: I'm going to PA school! I will start this fall, and it is a big accomplishment to be accepted. I'm excited to move my healthcare career forward. I will miss the camaraderie of my current workplace, but look forward to new and different challenges. 

I believe I can better attain the way of life I desire in this new career path, while maintaining my commitment to service. As much as I enjoy my leisure and outdoor pursuits, I know that at my core, service is something I can't stray from. Perhaps this is why that passage sticks with me--"seek to make your life long and its purpose in the service of your people."

Calls that stick with you

Dear Lewis-

You are often in my thoughts. One of those cliché patients that sit on a healthcare provider’s shoulder as a constant reminder of events past.

We always move quickly at my station, when a call comes in. There are a few things that make everyone snap-to a little quicker, and a child gunshot wound is one of those things. So please know, we came as fast as humanly possible.

Usually when guns are involved, we wait until the cops have cleared the area before we enter. This time, we came in on the cops’ heels, knowing it was you. I’m not saying this was a smart idea, or that I recommend it to others, but we wanted to give you the best chance possible.

It was so quiet when we got to your apartment, Lewis. Quiet like no apartment full of children should be. I wish I could have known you earlier–I definitely liked your superhero pajamas. You were a superhero that day, very brave.

I want you to know you had a great pre-hospital crew take care of you. My partner and the firefighter we brought with us are some of the best paramedics I know. The silence in your apartment followed us in the ambulance though, each of us pulling silently for you. We were quick, with our scene time. We were quick to help you breathe, to give you fluids, and then to give CPR. We were quick to the trauma center.

Unfortunately, some things are beyond our control. Some traumas damage the human body beyond our control.

My heart aches with sorrow that you’ve moved on, but I’m trying to fill that with warmth that you may be in a safer and happier place. Five years old is too young for the things you’ve experienced. May you find peace.

One for Ten

As is not unusual for me, it's been quite a while between posts. I've wanted to write, and even have a couple of ideas for posts stashed up....but ultimately what drives me to write is emotional release, positive and negative. Lately it's been a lot of negative energy. I've been frustrated with conditions at my employer, as well as the state of EMS in general. That being said, I thought I'd write a post about what keeps those of us in EMS going. 

A friend I went to paramedic school with recently had this status update:

Gotta love the EMS shift with no death, drunks, or drama....just a healthy newborn baby girl! Best job on the world!

That, friends, is in a nutshell what keeps us going. Depending on who you talk to, statistics in EMS range from 10-20% of the calls we run being the "serious" calls. That is, calls for help from people that are in that true life or death scenario. So, for every twenty calls I run, it's a pretty sure bet that 16 to 18 of those are going to be (to use a technical term) bullshit. 

.....47 year old female panicking because she "doesn't know what to eat when her stomach is upset..."

.....chronic drunk we are called to because he was sleeping in public and someone called in a "man down..."

.....same drunk calling because it's cold and he knows the ER is warm...

.....person calling FROM THE ER because the "wait is too long".....

In addition to the bullshit, there are the serious calls that take a little from your soul. It's the loved one that arrests in front of their family, that's too far gone for us to save. Chronically ill kids. Teens in a car wreck from drinking and driving.

The list goes on and on. It can grind one down as well, especially in a busier system. My medic unit averages 18-20 calls per 48 hours (closer to 30 this last rack). That's a lot of calls to wade through to hold out for that one.....

But we do. We all do. We tell war stories around the kitchen table of our "good" calls and take every complaint of chest pain from every drunk seriously, on guard for our 10%. 

When it comes, it is our junky high. Whether it is the sick respiratory patient (not being able to breath has to be one of the scariest things ever) that you can bring back from the edge of respiratory arrest, or the *rare* childbirth (nice job, Billy!), it is a call that stays with you. The "wins" buoy us through the storm, in the dark and frustrating moments that inevitably follow. There is nothing better than knowing that you have made a positive difference in a patient's life. That intimate moment and connection is unlike any other I have experienced.

Lately I have been feeling particularly run down. I rarely see that 10% any more. Coming back to the blog, to some introspection, I again come back to this quote. It helps give me some perspective.

To know even one life has breathed easier because you have lived.
This is to have succeeded.

Until next time....

Put me to work

It came to my attention recently that there are several people actually reading this. Thank you! I am humbled, as I mostly write off my ramblings as cheap therapy.

Anyway, I've been in a state of flux recently and to be honest haven't had anything too positive to write about. I feel that in some ways I have been boxed in by my system, and have reached a "stay or go"point.

The frustration is, I'm ready to work! I'm ready to be challenged as a paramedic, to provide excellent care to my patients. I want to receive more education, to participate in research and to have a voice in how our system evolves. However....I have no voice, budgets are reserved for "fire training," and I have about as much voice as an Army private in boot camp.

I don't think I am alone in this predicament. I'd like to see prehospital medicine (or paramedicine, as you may call it) flourish or even become established as a legitimate career in the US. I believe that EMS can be a part of building a stronger healthcare system. The days of a high speed taxi and low education should be gone. We are healthcare providers, not technicians that can follow an algorithm. I'd love to see EMS evolve to treat more in the field, for better patient outcomes and to ease the load on emergency departments. To the chagrin of many, I see this possible through increased primary care training. As my fellow practitioners know, many of our calls aren't for true "emergencies," but rather for primary health care issues from citizens who don't have access to the system.

Unfortunately....the current system is far from this utopia. Private EMS pays on par with what you might make flipping burgers at a fast food joint. Third service EMS constantly struggles for funding. Fire-based EMS....is often the butt of jokes in the world of EMS, and sometimes rightly so. It doesn't make sense to "force" a firefighter to become a paramedic, and doesn't lead to good patient care. It doesn't make sense to devote a majority of budget and personnel to training firefighters when fires make up less than 5% of all calls.

I'm making a call to those fire departments running their own EMS. Step up to the plate, and become part of the system. Take your medicine seriously, through your budgeting and training. Participate in the national discussion on EMS, and how it is changing. Participate in research. Now is a critical time for our field, and the fire-EMS system is the most well funded to facilitate change. The ambulance is not the bastard child of the fire department, the piece of apparatus to shy away from. Take pride in prehospital medicine, and take pride in your prehospital providers.

love,
MedicMuse.

Ah, Fall.

Apparently nothing worth blogging about happened over the summer. I can't say that with any certainty, but I don't (though I should) force myself to blog. It happens when it happens.

The newest news as of late is that I am dipping my toe into the educational and mentoring portion of paramedicine. Recently our rig has had two paramedic students, the most recent staying with us until mid-December. It has been very interesting being in a teaching position in the field, especially when many times I feel like I am still learning the ropes myself. The idea of teaching has always appealed to me. I've been told I'm good at explaining things and that "I'd make a great teacher."

That is not, however, how I feel.

I realized (not surprisingly) that I have high standards for street performance. I want people I work with to be at that standard right away, and it is a bit of a shock to see a student below that (duh, they're a student) and wondering how I'm going to get them from where they are to where I want them to be. Fortunately, my partner on the ambulance is an experienced field instructor and I've been able to pick up some good tips from him. As he put it, mentoring a student is a fine art of putting them on the line between uncomfortable and dangerous to practice. Apparently this zone is the best place to learn. 

Unavoidably, I've also compared both our paramedic students. I've come to the same conclusion I always have--this is a job field built largely on field experience. Most of our job, at the basic or advanced level, centers around being able to talk to people. If you can go up to a stranger and establish a rapport with them, as well as extract pertinent information in a concise and timely manner, you'll make a great pre-hospital provider. This comes to some naturally, while in the rest of us it takes many repetitions. I'm covering all this because I'm unhappy with the way paramedic education seems to be going in my state. Now, paramedic school started out as a two year deal. With the advent of fire-based EMS, programs were pressured to shorten their academies to accomodate agencies that needed more advanced providers in the field quickly. As a result, paramedic schools everywhere are cranking out paramedics in as little as six months. 

Experience also used to be a prerequisite to a paramedic program. EMTs with a couple years street experience on an ALS rig were considered the minimum when applying to a program. Now, however, there are too many "zero to hero" programs, where someone can become an EMT and then paramedic all in the same program with no street experience in between! Even worse, many fire departments (including my own), send inexperienced EMTs to school, EMTs who got their certification only so they could apply to the fire department. Does this product sound like someone you want treating your family?

Ah, I can see I've rambled again. Anyway. I'm sort-of precepting now and it's interesting.

EMS: A Primer

Ok, judging by the recent news story I feel it's again time to discuss the basics of my job. The news story I'm referring to is about the high cost of ambulance bills, and can be found here:

http://www.thedenverchannel.com/news/23557782/detail.html

EMS stands for Emergency Medical Services. Most commonly, this translates into ambulances. There are a number of different ways of providing ambulances to the public. One way is through a private company. This may be a for-profit or a not-for-profit endeavor. Alternatively, the service may be hospital-based, and the profit standpoint depends on the hospital. As an aside, these hospital-based systems don't "only" transport to their own hospital. The most common solution to providing ambulances in Colorado is in fire-based EMS. In this system, the fire department cross-trains its firefighters in EMS and run ambulances as well as engines and trucks. At our department, there is no difference beween who works where--I may work on an engine one day and the ambulance the next. It is a non-profit endeavor.

Now, onto who works on an ambulance. There are three levels of certification. EMT (Emergency Medical Technician)-Basic, EMT-Intermediate, and EMT-Paramedic. EMT-Intermediates are found mostly in rural areas, so I will focus on EMT-Bs and Paramedics. EMTs provide BLS (Basic Life Support). They take vitals, perform exams, provide oxygen, and perform techniques ranging from CPR to IV cannulation to artificial ventilation.

Paramedics are the most advanced form of pre-hospital EMS. They have all the skills of an EMT plus some. They go to school for a longer period of time, and perform more detailed exams. They have a number of drugs they can administer to treat respiratory problems, allergic reactions and cardiac dysrhythmias. They can intubate, perform synchronized cardioversion and defibrillate, among other things.

At our department, an ambulance consists of an EMT and a paramedic, or two paramedics. Some things we can't do: kidnap people against their will, diagnose diseases, make your decisions for you, provide parenting advice or parent your children.

Now, what happens when 911 is called? For a medical emergency, the nearest fire engine and ambulance are dispatched to your location. Why two rigs? There are more engines than ambulances, so an engine will usually reach you first to provide care (remember, EMTs and paramedics are on all the engines). Also, on a seriously ill patient, more hands can help the call run more smoothly. We aim for a response time of under five minutes, and have to be out of the station in under a minute after receiving tones. Want to try it out? Here are two fun ways at home. First, get into the shower. Lather up. Relax. Then start the stop watch and make it out of the shower, dressed and sitting in your car. Don't want to soak your seats? Get into bed. Fall asleep. Deeply asleep. Have your alarm go off at 0230, in the dark. Again, get dressed, out to your car. One minute.

So, we've arrived where you are. A number of things can happen. Usually, you describe your complaint, we evaluate you, and off we go to the hospital. However, there are times where the "patient" isn't the one who called 911. They may not wish to go with us to the hospital, preferring to have someone take them, or they may not wish to go at all. Sometimes this is reasonable, sometimes they are making a poor health decision. Either way, we can't kidnap them. They can refuse, against medical advice and after consultation with our base physician at the emergency department. What we can't do is "paramedic initiated refusals;" that is, refusing to take you to the hospital. If it is a minor injury, we can explain that it may be a better decision to seek care at an urgent care, your personal physician, or have someone drive you to the emergency department. But if you want to go to the ED, we'll take you.

This brings up the question of cost. Yes, it does cost for us to take you to the hospital. Sometimes a lot. No, I don't know how much it will cost. Administration won't tell us. And we've been told that if we do know, we can't tell you. So someone gave you an estimate? Well, it's not based on anything. Your bill is higher? Sorry--it was uninformed. Here's the deal though. When you call 911, you get the jurisdiction covering your area. It's not a "shop around" type of deal. The services that respond are paid by your tax dollars.

So, you ask, if I pay taxes for these services, why isn't my ambulance ride free? Good question. It turns out taxes pay for the stations, salaries, rigs, rig maintenance, keeping our training up to date, etc. It doesn't cover the wear and tear on ambulances, fuel costs, drug costs or other supplies. So we have to charge. Again, we're not making a profit. Additionally, there are health insurance companies to deal with. Some reimburse us only pennies on the dollar. The last average ambulance reimbursement figure I heard thrown around was 30%. This is why fire-based EMS is popular in Colorado. The fire department is supported by a consistant tax base, not by ambulance fees. This is also why so many private ambulance companies go out of business. Imagine running a business where you took up to a 70% loss on every transaction.

Abuse of the 911 system adds to these costs. Think of the number of people, with or without insurance, that take the ambulance frivolously (yeah, there's a lot of them). There's the ones with a cold for three weeks that call at 3am for an ambulance ride. The drunk on the street who we will transport twice in one night. The minor cuts and scrapes, not to mention the "neck pain" patients from car wrecks hoping for an insurance payout. There's people that are "frequent flyers," known to EMS crews and ED staff by name. These aren't unusually sick people, just drunks or those with imaginary illnesses.

These patients spill over into overcrowding in the emergency department. In a place that is supposed to be reserved for life threatening illnesses, nowadays you find a majority of patients that should be seen instead by their primary care doctor. This brings us to another problem--many people lack health insurance to have a primary doctor, and thus use the emergency medical system as their primary care.

As you can see, this is a problem that quickly grows in size and complexity as it is unwrapped. I don't foresee a simple solution--my goal is to educate you to the issues at hand.

Please, just remember a few points.

-We're not "ambulance drivers."
-We're not gunning for a profit. We are healthcare workers concerned about your health.
-Please use common sense before dialing 911. If you have no common sense, please consult someone with some.
-For those of you against healthcare for everyone, remember that next time you or a loved one is waiting for hours in an overcrowded emergency department waiting to be seen.
-If you insist on calling 911 from your cell phone for a car wreck or a person "passed out" in the grass/bus stop/alley and you DON'T stop to render aid or wait for us to show up...I will hunt you down and you will lose phone privileges.

Thanks for reading.

Reentry

TJ and I are on the final leg of our journey home. PAP-MIA-JFK-MIN-DEN. It's been a log, hard, heartbreaking and rewarding week. We are both a bit run into the ground, and on top of it TJ has contracted some sort of respiratory gunk.

We feel as though we've been on the ground for a lot longer than a week. It seems weak to say that...I look around at other healthcare providers with a thousand-yard stare, and realize they've only been on the ground for twice our time.

After virgin bloody mary's on one leg of the flight, we suck it up and have a morning commemorative shot of whiskey in Minnesota. It burns in a good way after spending the night at JFK.  On the final leg home we recount the highs and lows of the trip. Most are recounted here. Most. Writing this blog, in the past/present tense, I realized that there are some stories that just aren't to be told. I've taken you for the most part day by day through our experience, and I hope this gives you an idea of what it was like. TJ and I agree though, that some stories we carry with us, though seldom share.

I feel as though we've seen humanity at its best and worst this trip. We've seen those operating on the most primitive survival instincts, and those whose compassion only grows in the face of adversity. There have been those that have become adoptive parents to children orphaned by the earthquake. There have been those that have split their families in hopes of self-preservation and a better life for their children. This is a country where adults rarely smile, and never complain. Children innocent to their situation keep smiles alive.

I worry about the mental health component of all this. Everyone we met has some sort of PTSD. It appears that no one sleeps. Some weep silently. Others speak of night terrors and loved ones screaming in their sleep. Our translators speak of even further horrors in outlying refugee camps that have seen little aid.

Coming back, it is odd to take up the life I left here. It is easy to feel guilty for the situation I find myself in. I remind myself often, that I should feel grateful rather than guilty. And a duty to help others. I know that Haiti will remain in my heart and my mind, a place that remains in need long after the media has left.  Thanks for reading.